Provider Demographics
NPI:1053316901
Name:MIDDAUGH, GLEN D (DDS)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:D
Last Name:MIDDAUGH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 ANTON ROAD
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47803
Mailing Address - Country:US
Mailing Address - Phone:812-877-6724
Mailing Address - Fax:812-877-6150
Practice Address - Street 1:2801 ANTON ROAD
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47803
Practice Address - Country:US
Practice Address - Phone:812-877-6724
Practice Address - Fax:812-877-6150
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010393122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200415160AMedicaid